ILLINOIS HEALTH CONNECT FACT SHEET

 

ELIGIBLE Populations = 1.6 million

·        Children in the current All Kids Program (1,100,000)

·        Parents in the FamilyCare Program (400,000)

·        Adults with Disabilities and Elderly (100,000)  

EXCLUDED Populations:

·        People who have Medicare

·        Children under age 21 who get Supplemental Security Income (SSI)

·        Children in foster care and children who get Subsidized Guardianship or Adoption Assistance from DCFS (Department of Children and Family Services)

·        Children under age 21 who are blind or who have a disability

·        People who live in nursing facilities

·        American Indians and Alaska Natives

·        Individuals with Spend-down

·        Refugees

·        People who get Home and Community-Based services like the Community Care Program, the Home Services Program, or community services for persons with developmental disabilities

·        Individuals residing in Community Integrated Living Arrangements (CILAs)

·        Individuals in Presumptive Eligibility programs

·        Individuals enrolled in the following programs with limited benefits:

ü      Illinois Healthy Women

ü      All Kids Rebate and FamilyCare Rebate

ü      Illinois Cares Rx (formerly SeniorCare/Circuit Breaker)

ü      Transitional Assistance, age 19 and older

ü      Emergency Medical Only

ü      Hospice

ü      Sexual Assault, Renal and Hemophilia Programs

·        Populations Already Managed:

ü      Individuals with High Level Third Party Liability (TPL)/Private Insurance

ü      Program for All-Inclusive Care for the Elderly (PACE) participants

·        Children under age 21 whose care is managed by the Division of Specialized Care for Children (DSCC) of the University of Illinois at Chicago

 Phase 1 – Voluntary

·        Began July 1, 2006 . 

·        PCPs limited to FQHCs, RHCs and Cook County Bureau of Health Services (CCBHS) to allow for immediate statewide presence. 

·        Enrollment materials available in FQHC/RHC/CCBHS offices for their existing patients who are interested in enrolling in the voluntary phase. 

·        Clients will mail their enrollment forms to the State or ask their PCP to fax their enrollments forms to the State.

·        Enrollees may disenroll at any time.  

Phase 2 – Mandatory

·        Geographical implementation: 

§         Mandatory enrollment began in the Cook and Collar Counties on February 16, 2007 .

§         Mandatory enrollment began in the Northwest Region on May 29, 2007 .

§         Mandatory enrollment will proceed in the Central and Southern Regions within the next few months.

·        Client Enrollments handled by State Contractor – Automated Health Systems:

ü      An Initial Client Enrollment packet will be mailed to households with potential enrollees.

ü      The Initial Client Enrollment packet will include:

·          a cover letter

·          an Information Guide

·          Enrollment Tips for picking a PCP

·          an Enrollment Form, personalized with each client’s name, ID number and date of birth (DOB)

·          a postage-paid return envelope. 

ü      The enrollment material will identify the potential enrollees in each household that must pick a PCP, explain client’s health care choices, give a timeframe for making a choice and explain how to enroll. 

ü      Clients may choose their PCP and enroll by mail, phone, or online.

ü      A Second Client Enrollment packet will be mailed to clients who have not responded to the Initial Client Enrollment packet within 30 days.

ü      The Second Client Enrollment packet will include:

·          a cover letter with the name of the PCP to whom the client will be assigned if they do not make a choice within 30 days

·          a second enrollment form, personalized with each client’s name, ID number and DOB

·          a postage-paid return envelope. 

ü      The auto assignment process will take into account existing provider-client relationships as determined by voluntary phase enrollment and HFS claims data, PCPs of other family members, location and language preferences, provider specialty and capacity limits.

·        Clients already enrolled with an MCO or an FQHC/RHC/CCBHS under the voluntary program will go through mandatory enrollment process so as to provide all health care choices to beneficiaries.  If they do not choose, they will be auto-assigned to their current provider/MCO.

·        Enrollees may change their PCP, and if applicable their health plan, for any reason, once a month.

·        Enrollees will receive a letter to confirm their enrollment.

·        Each PCP will receive a monthly client roster for all clients enrolled with that PCP as of the first of each month.

·        Providers should always check client eligibility/PCP assignment prior to providing service through the HFS website (MEDI system) or through the use of a REV vendor.

·        PCPs will not be listed on the HFS or All Kids medical card.  

Primary Care Case Management (PCCM) is a managed care model in which each enrollee has a medical home with a primary care provider (PCP).  Enrollees may pick their own primary care doctor or clinic as their PCP if that provider is enrolled with HFS as a PCP and enrolled with Illinois Health Connect.  For those who do not choose a PCP, they will be assigned to one.   

A medical home ensures that each PCP knows about the health care their enrollees receive which:

·        ensures enrollees get immunizations and other preventative health care 
·        prevents duplication of services
·        ensures enrollees receive the most appropriate level of care
·        improves the quality of care that an enrollee receives. 

Providers Eligible to be PCPs: (must meet ALL PCP requirements)

·        General Practitioners, Internists, Pediatricians, Family Practitioners, OB/GYNs, and other Specialists
·        Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and other clinics including certain specified hospitals and Cook County Bureau of Health Service clinics
·        Certified local health departments 
·        School-Based/Linked clinics
·        Other qualified health professionals as authorized by HFS

Monthly Care Management Fee

PCPs will be paid a special monthly care management fee for each person whose care they are responsible to manage:

• $2.00 per child

• $3.00 per adult

• $4.00 per disabled or elderly enrollee

This care management fee will be paid monthly, even if the enrollee does not utilize a service that month.  PCPs will continue to receive reimbursement from HFS for their services using current established rates.  

Panel Sizes

·        Each physician enrolled as a PCP may have up to a maximum of 1,800 enrollees.  

·        For each nurse practitioner or physician assistant affiliated with the physician, the maximum increases by 900 enrollees. 

·        The maximum panel size for residency programs is 900 enrollees per resident.

·        PCPs may limit the number of enrollees and may opt out of auto-assignment.

Nurse Practitioners, Midwives, and Physician Assistants

·        HFS will allow nurse practitioners, midwives and physician assistants to participate by providing services with an affiliated physician. 

·        In areas where there may be a limited availability of PCPs to sufficiently meet the demand, HFS may approve advanced practice nurses to directly enroll as PCPs.

·        This may be expanded if determined in the best interest of the program by HFS.

PCPs must agree to provide medically necessary care in a timely manner with a focus on the provision of quality primary and preventive health care services that support continuity of care initiatives and avoid unnecessary emergency room visits and hospitalizations. 

 Specific requirements include:

·        Enroll with HFS as one of the allowed provider types.

·        Maintain hospital admitting and/or delivery privileges or arrangements for admission.

·        Make medically necessary referrals to HFS enrolled providers, including specialists, as needed.

·        Provide direct access to enrollees through an answering service/paging mechanism or other approved arrangement for coverage twenty-four hours a day, seven days a week. Automatic referral to hospital ER does not qualify.

·        Maintain office hours of at least 24 hours/week (solo practice) or 32 hours/week (group)

·        Agree to maintain appointment standards:

ü      Routine, preventive care available within five weeks from request, but within 2 weeks for infants less than 6 months, from the date of request for such care.

ü      Urgent care appointments not deemed emergency medical conditions triaged and, if deemed necessary, provided within 24 hours.

ü      Appointments for Enrollee problems or complaints not deemed serious available within 3 weeks from the date of request for such care.

ü      Initial prenatal appointments without expressed problems: 1^st trimester within 2 weeks, 2^nd trimester within 1 week, 3^rd trimester within 3 days.

ü      Upon notification of Enrollee hospitalization or ER visit, follow-up appointment available within 7 days of discharge.

·        Agree to provide and coordinate Maternal and Child Health Services (if providing services to pregnant women and children):

ü      Perform periodic preventive health screenings in accordance with established standards of care.

ü      Perform risk assessments for pregnant women and children and provide obstetrical care or delivery services.

ü      Schedule, or coordinate with a case manager to schedule, diagnostic consultation and specialty visits and communicate with the case management entity.

·           Agree to institute a symptom-based action plan of care to be shared with Enrollees with chronic diseases.

·           Meet other requirements as detailed in the PCP Agreement.